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The impact of sex on allergic bronchopulmonary aspergillosis (ABPA) outcomes remains uncertain. We retrospectively included ABPA subjects per the revised International Society for Human and Animal Mycology ABPA working group criteria over 13 years. We compared the clinical features, lung function, immunological tests, imaging, and ABPA exacerbation rates between men and women. Our primary objective was to assess whether women experience higher ABPA exacerbations than men. We included 731 ABPA subjects (mean age, 34.5 years; 49.5% women). Women with ABPA were older and had underlying asthma more frequently than men. There was no difference in lung function, immunological investigations, and imaging between men and women. ABPA exacerbations occurred in a slightly higher proportion of women than men (44.5% vs. 38.2%) but did not reach statistical significance (p = 0.09). We did not find a significant sex difference in ABPA exacerbation rates. Prospective studies should confirm our findings., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Sensitization to Aspergillus fumigatus (AS) has been recently described in chronic obstructive pulmonary disease (COPD) patients. However, there is no data on the community prevalence of AS in COPD., Objectives: To assess the prevalence of AS among COPD subjects. The secondary objectives were to (1) assess the prevalence of allergic bronchopulmonary aspergillosis (ABPA) in COPD and (2) compare the lung function in COPD subjects with and without AS., Methods: We conducted a cross-sectional study in rural (29 villages) and urban (20 wards) communities in North India. We identified individuals with respiratory symptoms (IRS) through a house-to-house survey using a modified IUATLD questionnaire. We then diagnosed COPD through specialist assessment and spirometry using the GOLD criteria. We assayed A.fumigatus-specific IgE in COPD subjects. In those with A. fumigatus-specific IgE ≥0.35 kUA/L (AS), ABPA was diagnosed with raised serum total IgE and raised A.fumigatus-specific IgG or blood eosinophil count., Results: We found 1315 (8.2%) IRS among 16,071 participants >40 years and diagnosed COPD in 355 (2.2%) subjects. 291 (82.0%) were men and 259 (73.0%) resided in rural areas. The prevalence of AS and ABPA was 17.7% (95% CI, 13.9-21.8) and 6.6% (95% CI, 4.4-8.8). We found a lower percentage predicted FEV1 in COPD subjects with AS than those without (p =.042)., Conclusions: We found an 18% community prevalence of AS in COPD subjects in a specific area in North India. Studies from different geographical areas are required to confirm our findings. The impact of AS and ABPA on COPD requires further research., (© 2024 Wiley‐VCH GmbH. Published by John Wiley & Sons Ltd.)

Background: Various methods are available to screen for allergic bronchopulmonary aspergillosis (ABPA) in asthma, but their comparative performance remains uncertain., Objectives: To identify the optimal screening algorithm for ABPA in asthmatic patients and evaluate the crude cost of various diagnostic approaches., Methods: We performed a post hoc analysis of prospectively collected data from consecutive adult asthmatic patients evaluated for ABPA. The diagnosis was based on the revised International Society for Human and Animal Mycology ABPA Working Group criteria. Initial evaluations included measurements of serum Aspergillus fumigatus -IgE (≥0.35 kUA/L), serum total IgE (≥500 IU/mL), serum A. fumigatus -IgG (≥27 mgA/L), blood eosinophil count (BEC ≥500 cells/μL), and chest CT findings. A decision tree was manually constructed using recursive partitioning to identify the most effective diagnostic pathway., Results: Among 543 adult asthmatics, 106 were diagnosed with ABPA. Serum A. fumigatus -IgE was positive in 221 (40.7%) patients, while serum total IgE was elevated (≥500 IU/mL) in 300 (55.3%) patients. The serum total IgE-based approach required 196 additional tests during screening, compared to 115 in the A. fumigatus -IgE method. The BEC-based strategy missed 28 cases of ABPA. Although the CT-directed protocol had the fewest false positives, it required 437 additional screening radiographic procedures and missed eight ABPA cases. The A. fumigatus -IgE pathway emerged as the most cost-effective, whereas imaging-based strategies were the most expensive., Conclusions: Serum A. fumigatus- IgE is the optimal screening test for ABPA in asthma. It minimizes unnecessary testing while maintaining high diagnostic accuracy, making it a preferable approach in clinical practice.

Objective: Aspergillus sensitisation (AS) is seen in many patients with chronic pulmonary aspergillosis (CPA). However, the clinical relevance of AS in CPA remains unclear. In this study, we assess the clinical significance of AS in CPA., Methods: We retrospectively analysed the data of CPA subjects, defining AS as Aspergillus fumigatus-IgE ≥ 0.35 kUA/L. We excluded subjects with asthma, allergic bronchopulmonary aspergillosis, chronic obstructive pulmonary disease (COPD) and diffuse parenchymal lung diseases (DPLD). The primary objective was to compare the demographic and clinical characteristics, lung functions (via spirometry) and treatment outcomes in CPA subjects with or without AS. The secondary objective was to explore the association between AS and airflow obstruction on spirometry using multivariable logistic regression analysis., Results: We included 232 CPA subjects (119 females, 113 males) with a mean ± SD age of 42.1 ± 13.7 years. AS was present in 92 (39.7%) CPA patients (CPA-AS group). CPA-AS patients had higher SGRQ total scores, a higher prevalence of fungal ball, more frequent airflow obstruction and experienced more CPA relapses during follow-up compared to those without AS. Airflow obstruction was seen in 77/232 (33.2%) CPA patients. On multivariable logistic regression analysis, we found AS, increasing age and chronic fibrosing pulmonary aspergillosis independently associated with airflow obstruction on spirometry after adjusting for sex and other CPA categories. The relapse-free survival was significantly shorter in the CPA-AS group than in the CPA group., Conclusion: AS is common in CPA and is independently associated with airflow obstruction. More studies are required to confirm our findings., (© 2024 Wiley‐VCH GmbH. Published by John Wiley & Sons Ltd.)

Background: Allergic bronchopulmonary aspergillosis (ABPA) is thought to occur more frequently in severe than in mild asthma. However, there are no precise data to support this hypothesis., Objective: To determine the prevalence of ABPA in subjects with varying asthma severity., Methods: We conducted a secondary analysis of prospectively collected data from 543 adult asthma subjects classified according to the 2004 Global Initiative for Asthma (GINA) guidelines. The asthma severity was categorized into mild, moderate, and severe. We report the prevalence of ABPA in each asthma category. We also performed multivariable logistic regression analysis to identify factors associated with ABPA in subjects with asthma., Results: We classified 81 (15%), 257 (47%), and 205 (38%) subjects as mild, moderate, and severe asthma. We diagnosed ABPA in 106 (19.5%) subjects. The prevalence of ABPA was 11.1% (9 of 81) in mild, 21% (54 of 257) in moderate, and 20.7% (43 of 205) in severe asthma (P = .12). Multivariable analysis identified age and asthma duration as significant factors associated with ABPA, whereas asthma severity was not significantly associated., Conclusions: The prevalence of ABPA does not vary significantly with the severity of asthma. These findings support the revised International Society of Human and Animal Mycology (ISHAM) ABPA working group (AWG) recommendation for screening all asthma patients for ABPA, irrespective of asthma severity. Further large-scale studies across different geographic regions are warranted to validate these findings., (Copyright © 2024 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: The utility of two disease-severity indices, namely bronchiectasis severity index (BSI) and FACED score in allergic bronchopulmonary aspergillosis (ABPA) remains unknown., Objective: To correlate the BSI and FACED scores with immunological parameters (serum IgE [total and A. fumigatus -specific], A. fumigatus -specific IgG, blood eosinophil count), and high-attenuation mucus on chest computed tomography in ABPA. The secondary objectives were to evaluate the correlation between BSI and FACED scores and correlate the BSI/FACED scores with the bronchiectasis health questionnaire (BHQ) and Saint George's Respiratory Questionnaire (SGRQ)., Methods: We included treatment-naïve ABPA subjects with bronchiectasis in a prospective observational study. We computed the BSI and FACED scores for each subject before initiating treatment. The subjects also completed two quality-of-life questionnaires (BHQ and SGRQ)., Results: We included 91 subjects. The mean (standard deviation) BSI and FACED scores were 3.43 (3.39) and 1.43 (1.27). We found no correlation between BSI or FACED with any immunological parameter or high-attenuation mucus. There was a strong correlation between BSI and FACED scores ( r  = 0.76, p  < 0.001). We found a weak correlation between BSI and BHQ/SGRQ and FACED and SGRQ., Conclusion: We found no correlation between BSI and FACED with immunological parameters in ABPA. However, we found a significant correlation between BSI and FACED and a weak correlation between SGRQ and BHQ. ABPA likely requires a separate disease-severity scoring system.

Background: Post-tuberculosis lung abnormality (PTLA) is the most common risk factor for chronic pulmonary aspergillosis (CPA), and 14%-25% of the subjects with PTLA develop CPA. The pathogenesis and the host immune response in subjects with PTLA who develop CPA need to be better understood., Methods: We prospectively compared the innate and adaptive immune responses mounted by patients of PTLA with or without CPA (controls). We studied the neutrophil oxidative burst (by dihydrorhodamine 123 test), classic (serum C3 and C4 levels) and alternative (mannose-binding lectin [MBL] protein levels) complement pathway, serum immunoglobulins (IgG, IgM and IgA), B and T lymphocytes and their subsets in subjects with PTLA with or without CPA., Results: We included 111 subjects (58 CPA and 53 controls) in the current study. The mean ± SD age of the study population was 42.6 ± 15.7 years. The cases and controls were matched for age, gender distribution and body weight. Subjects with CPA had impaired neutrophil oxidative burst, lower memory T lymphocytes and impaired Th-1 immune response (lower Th-1 lymphocytes) than controls. We found no significant difference between the two groups in the serum complement levels, MBL levels, B-cell subsets and other T lymphocyte subsets., Conclusion: Subjects with CPA secondary to PTLA have impaired neutrophil oxidative burst and a lower Th-1 response than controls., (© 2024 Wiley‐VCH GmbH. Published by John Wiley & Sons Ltd.)

Background & objectivesAcute respiratory distress syndrome (ARDS) is a common disorder in critically ill patients and is associated with high mortality. There is a paucity of literature on this condition from developing countries. This prospective observational study was designed to find out the aetiology, outcomes and predictors of mortality in ARDS.MethodsSixty four consecutive patients who satisfied American-European Consensus Conference (AECC) definition of ARDS from medical Intensive Care Unit (ICU) of a tertiary care centre in New Delhi, India, were enrolled in the study. Demographic, biochemical and ventilatory variables were recorded for each patient. Baseline measurements of serum interleukin (IL)-1β, IL-6, tumour necrosis factor-alpha (TNF-α), procalcitonin (PCT) and high sensitivity C-reactive protein (hsCRP) were performed.ResultsCommon causes of ARDS included pneumonia [44/64 (68.7%)], malaria [9/64 (14.1%)] and sepsis [8/64 (12.5%]. Eight of the 64 (12.5%) patients had ARDS due to viral pneumonia. The 28-day mortality was 36/64 (56.2%).Independent predictors of mortality included non-pulmonary organ failure, [Hazard ratio (HR) 7.65; 95% CI 0.98-59.7, P=0.05], Simplified Acute Physiology Score (SAPS-II) [HR 2.36; 95% CI 1.14-4.85, P=0.02] and peak pressure (P peak ) [HR 1.13; 95% CI 1.00-1.30, P = 0.04] at admission.Interpretation & conclusionsBacterial and viral pneumonia, malaria and tuberculosis resulted in ARDS in a considerable number of patients. Independent predictors of mortality included non-pulmonary organ failure, SAPS II score and P peak at baseline. Elevated levels of biomarkers such as TNF-α, PCT and hsCRP at admission might help in identifying patients at a higher risk of mortality.

Background: The long-term outcomes of allergic bronchopulmonary aspergillosis (ABPA) are poorly characterised., Methods: We retrospectively included treatment-naïve subjects of acute stage ABPA-complicating asthma from three randomised trials. All the subjects received oral prednisolone for 4 months and were monitored every 6 weeks for 6 months and then every 6 months. Our primary objective was to estimate the incidence rate and the frequency of subjects experiencing ABPA exacerbation. The key secondary objectives were to evaluate the factors predicting ABPA exacerbation and the changes in serum total IgE seen during treatment., Results: We included 182 subjects. Eighty-one (44.5%) patients experienced 120 exacerbations during 512 patient-years of follow-up. The incidence rate of ABPA exacerbations was 234/1000 patient-years. Most (73/81, 90.1%) subjects experienced ABPA exacerbation within three years of stopping therapy. On multivariate logistic regression analysis, peripheral blood eosinophil count ≥1000 cells/μL (adjusted odds ratio [aOR] 2.43; 95% confidence interval (CI), 1.26-4.67), the extent of bronchiectasis (aOR 1.10; 95% CI, 1.03-1.18), age (aOR 0.97; 95% CI, 0.94-0.99), and female sex (aOR 2.16; 95% CI, 1.10-4.24) independently predicted ABPA exacerbation after adjusting for serum total IgE and high-attenuation mucus. The best cut-off for serum total IgE after 6 weeks for identifying treatment response and ABPA exacerbations was a 20% decline and a 50% increase, respectively., Conclusions: ABPA exacerbations were common within 3 years of stopping treatment. Age, female sex, peripheral blood eosinophilia and the extent of bronchiectasis predicted ABPA exacerbations. The optimal serum total IgE cut-off for defining ABPA response and exacerbations is a 20% decline and a 50% increase, respectively., (© 2023 Wiley-VCH GmbH. Published by John Wiley & Sons Ltd.)

Purpose: The role of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) for diagnosing chronic pulmonary aspergillosis (CPA) remains unknown. Herein, we investigate the diagnostic performance of serum ESR and CRP in CPA., Methods: We retrospectively analyzed the data of treatment-naïve subjects with CPA and diseased controls (post-tuberculosis lung disease on CT thorax). We treated CPA subjects with six months of oral itraconazole. Our primary objective was to evaluate the sensitivity and specificity of ESR and CRP in diagnosing CPA. The key secondary objective was to study the change in the inflammatory markers with treatment., Results: We included 434 subjects and 20 diseased controls. The sensitivity and specificity of ESR (n = 434) and CRP (at cut-off value of 10 mg/L, n = 308) in diagnosing CPA were 42.9% and 65%, and 52.3% and 65%, respectively. Both ESR and CRP had erratic trend following treatment. ESR and CRP declined or remained stable in approximately 60% of subjects but increased in approximately 40% of the subjects despite treatment., Conclusion: Serum CRP and ESR have limited utility in diagnosing and following subjects with CPA., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: The chronic pulmonary aspergillosis network (CPAnet) has recently proposed definitions for treatment outcomes in CPA. However, these definitions need to be validated. Herein, we evaluate the agreement between the existing and the CPAnet definitions for response assessment., Methods: We enrolled consecutive treatment-naïve CPA subjects (between January 2021 and June 2021) who received six months of itraconazole therapy and followed them for an additional six months after treatment discontinuation. We retrospectively applied the CPAnet criteria and compared the agreement between the existing and the CPAnet criteria for response assessment (primary objective). We also assessed if adding weight loss (> 5% from baseline) as a component improved the performance of the CPAnet criteria., Results: We included 43 (mean age, 47.4 years) CPA subjects. The existing and the CPAnet criteria categorized 29 (67.4%) and 30 (69.8%) subjects as treatment success, respectively, at treatment completion. There was substantial (kappa = 0.73; p < 0.0001) agreement between the two definitions. However, both criteria did not identify eight subjects requiring treatment re-initiation within three months. There was an increment in the sensitivity of both criteria (by 36%) for identifying treatment failure after incorporating ≥ 5% weight loss as an element of worsening., Conclusion: The CPAnet definitions correctly categorized treatment outcomes in most cases of CPA. The addition of weight change would further enhance the performance of the CPAnet treatment outcome definitions., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Several genetic variants are associated with the risk of idiopathic pulmonary fibrosis (IPF). These have not been systematically reviewed., Methods: We searched the PubMed, Embase and GWAS Catalog databases for studies indexed between inception and 15 January 2024 describing genetic variants associated with IPF susceptibility. We included studies describing common associated single nucleotide polymorphisms (SNPs). We excluded studies describing rare variants, non-SNP variants and those without an allelic model analysis. We recorded study type, participant characteristics, genotyping methods, IPF diagnostic criteria, the SNPs and the respective genes, odds ratios, and other details. We also searched databases for functions of the identified genes., Results: The primary search retrieved 2697 publications; we included 42 studies. There were nine genome-wide association/linkage studies, while 27 were candidate gene studies. The studies included 22-11 160 IPF subjects. 88 SNPs in 58 genes or loci were found associated with IPF susceptibility. MUC5B rs35705950 was the most studied SNP. Most (n=51) SNPs were in the intronic or intergenic regions; only 11 were coding sequence variants. The SNPs had odds ratios ranging from 0.27 to 7.82 for an association with IPF. Only 22 SNPs had moderate-large effects (OR >1.5 or <0.67). Only 49.1% of the associated genes have a known functional role in IPF; the role of G protein-related signalling and transcriptional regulation (zinc-finger proteins) remain unexplored., Conclusion: Several common SNPs in over 50 genes have been found associated with IPF susceptibility. These variants may inform gene panels for future studies (PROSPERO CRD42023408912)., Competing Interests: Conflict of interest: All authors have nothing to disclose., (Copyright ©The authors 2024.)

Background and Objective: There is a need for simple functional test to assess treatment response in chronic pulmonary aspergillosis (CPA) in resource-constrained settings. The one-minute-sit-to-stand test (1-min-STS) is one such test. However, the minimal important difference (MID) for 1-min-STS in subjects with CPA remains unknown. Herein, we estimate the MID for 1-min-STS for CPA subjects., Materials and Methods: We retrospectively reviewed the clinical details of CPA subjects treated with oral azoles for 6 months. We included only subjects who completed the 1-min-STS test at baseline and 6 months. We used the change in VAS (visual analogue scale, for overall improvement) as an external anchor. We used the anchor and the distribution (standard deviation-based) methods to determine the MID estimates. We used the anchor-based method only if there was correlation of 0.3 with the 1-min-STS test., Results: One hundred-eight subjects completed the 1-min-STS test at baseline and 6 months. We did not find significant correlation between the change in VAS for overall improvement (r2 = 0.024, P value = 0.809) and the 1-min-STS test. The MID for the 1-min-STS test was 2 repetitions (range, 1.5-2.8 repetitions)., Conclusion: The MID for the 1-min-STS test in subjects with CPA was 2 repetitions. Future studies using a global rating of change scale as an anchor must confirm our findings., (Copyright © 2024 Copyright: © 2024 Indian Chest Society.)

Background: The role of 2-deoxy-2-18(F) fluoro-D-glucose (FDG) positron emission tomography (PET)-computed tomography (CT) in assessing treatment response in chronic pulmonary aspergillosis (CPA) remains to be determined., Objective: To compare changes in FDG-PET/CT parameters in CPA subjects with treatment success or failure., Methods: We treated consecutive treatment-naïve CPA subjects with six months of oral itraconazole. We performed PET-CT at baseline and six months. A multi-disciplinary team categorized response as treatment success or failure. We recorded the maximum standardised uptake value (SUVmax), SUVpeak, and total glycolytic activity (TLG). After treatment, FDG uptake similar to the background uptake or ≥13 units decline in Z-score was considered a complete metabolic response (CMR). A >25%, >30%, and > 45% decline in SUVmax, SUVpeak, and TLG was labelled as a partial metabolic response (PMR). A >30%, >30%, or >75% increase in the SUVmax, SUVpeak, and TLG represented progressive metabolic disease., Results: We included 94 CPA subjects (63 males) with a mean age of 46.2 years. A follow-up PET-CT was performed on 77 subjects. We recorded treatment success and failure in 43 and 34 subjects. The median SUVmax at baseline was 6.7, which significantly reduced with treatment. CMR was seen in 18.6% of those with treatment success and none with treatment failure. A higher proportion of subjects with treatment success achieved PMR. 19% of the subjects with treatment success had progressive metabolic disease., Conclusion: FGD-PET/CT demonstrated metabolic activity in all CPA subjects. Most PET-CT parameters improved with treatment; however, one-fifth of the subjects were misclassified on PET-CT., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Three techniques have been described for aspirating the bronchoalveolar lavage (BAL) fluid, namely the wall mount suction (WMS), manual suction (MS), and manual suction with tubing (MST). However, there is no direct comparison among the 3 methods., Methods: We randomized patients undergoing flexible bronchoscopy and BAL in a 1:1:1 ratio to one of the 3 arms. The primary outcome was to compare the optimal yield, defined as at least 30% return of volume instilled and <5% bronchial cells. The key secondary outcomes were the percentage of volume and total amount (in millimeters) return of BAL, as well as complications (hypoxemia, airway bleeding, and others)., Results: We randomized 942 patients [MST (n = 314), MS (n = 314), WMS (n = 314)]. The mean age of the study population [58.7% (n = 553) males] was 46.9 years. The most common indication for BAL was suspected pulmonary infection. Right upper lobes and middle lobes were the commonest sampled lobes. The optimal yield was similar in all the groups [MST (35.6%) vs MS (42.2%) vs WMS (36.5%); P = 0.27]. A significantly higher proportion of patients had BALF return >30% (P = 0.005) in the WMS (54.2%) and MS (54%) than in the MST arm (42.9%). The absolute and the percentage volume of BALF was also higher in WMS and MS than in the MST arm. There was no difference in the complication rate or other secondary outcomes across the groups., Conclusion: We found no difference in the optimal yield of BAL or complications using any one of the 3 methods for BAL fluid retrieval., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Post-tuberculosis lung abnormality (PTLA) is the most common risk factor for developing chronic pulmonary aspergillosis (CPA). However, the prevalence and incidence of CPA in PTLA patients in India remain unknown., Objectives: We aimed to ascertain the incidence and prevalence of CPA in subjects with PTLA., Methods: We identified a cohort of pulmonary tuberculosis who completed anti-tuberculosis therapy (ATT) before November 2019 from the records of the 12 tuberculosis treatment centers attached to the national program. We recorded the clinical and demographic details. We performed computed tomography (CT) of the chest and estimated serum A. fumigatus-specific IgG. We categorised subjects as PTLA with or without CPA using a composite of clinical, radiological, and microbiological features. We resurveyed the subjects at 6 months (or earlier) for the presence of new symptoms. We calculated the prevalence and the incidence rate (per 100-person years) of CPA., Results: We included 117 subjects with PTLA, with a median of 3 years after ATT completion. Eleven subjects had CPA in the initial survey, and one additional case developed CPA during the second survey. The prevalence of CPA in PTLA subjects was 10.3% (12/117). The total observation period was 286.7 person-years. The median (interquartile range) time to develop CPA after ATT completion was 12.5 (5-36.7) months. We found the CPA incidence rate (95% confidence interval) of 4.2 (1.8-6.5) per 100-person years., Conclusion: Chronic pulmonary aspergillosis complicates 10% of PTLA subjects after successful outcomes with ATT. Four new CPA cases may develop per 100-persons years of observation after ATT completion. We suggest screening patients with PTLA who develop new symptoms for CPA., (© 2024 Wiley-VCH GmbH. Published by John Wiley & Sons Ltd.)

Background: Aspergillus fumigatus-specific IgG estimation is crucial for diagnosing allergic bronchopulmonary aspergillosis (ABPA). A point-of-care LDBio immunochromatographic lateral flow assay (LFA) had 0%-90% sensitivity to detect IgG/IgM antibodies against A. fumigatus., Objective: To assess the accuracy of LDBio-LFA in diagnosing ABPA, using the modified ISHAM-ABPA working group criteria as the reference standard. The secondary objective was to compare the diagnostic performance between LDBio-LFA and A. fumigatus-specific IgG (cut-offs, 27 and 40 mgA/L), using a multidisciplinary team (blinded to A. fumigatus-IgG and LDBio-LFA results) diagnosis of ABPA as the reference standard., Methods: We prospectively enrolled adult subjects with asthma and ABPA. We performed the LDBio-LFA per the manufacturer's recommendations. We used the commercially available automated fluorescent enzyme immunoassay for measuring serum A. fumigatus-specific IgG. We used the same serum sample to perform both index tests. The tests were performed by technicians blinded to the results of other tests and clinical diagnoses., Results: We included 123 asthmatic and 166 ABPA subjects, with a mean ± SD age of 37.4 ± 14.4 years. Bronchiectasis and high-attenuation mucus were seen in 93.6% (146/156) and 24.3% (38/156) of the ABPA subjects. The sensitivity and specificity of LDBio-LFA in diagnosing ABPA were 84.9% and 82.9%, respectively. The sensitivity of serum A. fumigatus-specific IgG ≥27 mgA/L was 13% better than LDBio-LFA, with no difference in specificity. There was no significant difference in sensitivity and specificity between LDBio-LFA and serum A. fumigatus-IgG ≥40 mgA/L., Conclusion: LDBio-LFA is a valuable test for diagnosing ABPA. However, a negative test should be confirmed using an enzyme immunoassay., (© 2024 Wiley-VCH GmbH. Published by John Wiley & Sons Ltd.)

Background: Brain metastases (BM) are common in metastatic nonsmall cell lung cancer (NSCLC). However, routine neuroimaging in asymptomatic patients with metastatic NSCLC is controversial as there is no conclusive evidence of benefit from the detection and treatment of asymptomatic BM. Herein, we evaluated the prevalence of asymptomatic BM and its treatment implications in a resource-limited setting., Methods: Consecutive patients with newly diagnosed, treatment-naïve, metastatic, nonsquamous NSCLC (NS-NSCLC) were included. Subjects who already had clinical or radiological features suggestive of BM were excluded from the study. All eligible subjects underwent contrast-enhanced magnetic resonance imaging (MRI) of the brain. Management of the detected BM was at the discretion of the treating clinicians., Results: Among 809 subjects who were screened, 100 (12.4%) were included in the study and underwent MRI. BM was present in 30 (30%) of the subjects and absent in the remaining 70 subjects. A majority of BM were multiple (70%), involved the frontal lobe commonly (73.3%), and had a mean (standard deviation) size of 13.2 (7.3) mm. Detection of BM resulted in a treatment alteration in 17 (17%) of the study subjects (brain irradiation, n = 17, change in targeted therapy, n = 3) with BM. There was no difference in survival of patients who underwent treatment alteration for management of BM compared to those who did not ( P = 0.132)., Conclusions: About one-third of patients with metastatic NS-NSCLC had BM in MRI despite the absence of symptoms. Despite treatment of the majority of the patients with BM with brain irradiation, there was no demonstrable survival benefit. Hence, we conclude that although routine neuroimaging of asymptomatic patients with newly diagnosed metastatic NSCLC may result in treatment alteration (primarily brain irradiation) in a small proportion of patients, it may not influence outcomes in resource-constrained settings., (Copyright © 2023 Copyright: © 2023 Indian Journal of Cancer.)

Background: Itraconazole capsules have variable and unpredictable bioavailability., Objective: Whether the generic brands are as effective as the innovator itraconazole in treating subjects with chronic pulmonary aspergillosis (CPA) remains unclear., Methods: In this retrospective study, we treated CPA subjects with 6-month itraconazole capsule and measured itraconazole levels at 2 weeks, 3 months and 6 months. Our primary outcome was to compare the proportion of subjects achieving therapeutic drug levels (≥0.5 mg/L) with the generic and the innovator itraconazole after 2 weeks. We performed a multivariate logistic regression analysis to ascertain whether trough itraconazole levels affected treatment outcomes. We categorised treatment response as favourable or unfavourable based on improvement (or worsening) in clinical symptoms, microbiology and imaging. We also performed morphometric analysis of different brands of itraconazole by video-dermoscopy., Results: We included 193 (generic brands [n = 94] and innovator itraconazole [n = 99]) CPA subjects. A higher proportion of subjects achieved therapeutic levels at 2 weeks with the innovator than with the generic brands (72/99 [73%] vs. 27/94 [29%], p < .0001). The median trough level at 2 weeks was higher with the innovator than the generic brands (0.8 vs. 0 mg/L). The mean trough itraconazole levels achieved (average of three values measured over 6 months) independently predicted a favourable treatment response after adjusting for age, gender and CPA severity. On morphometric analysis, the generic brands had variable pellet numbers and sizes, and dummy pellets., Conclusion: At 2 weeks, a significantly higher proportion of CPA subjects achieved therapeutic drug levels with the innovator than the generic itraconazole. The mean serum itraconazole levels independently predicted a favourable treatment response in CPA., (© 2023 Wiley-VCH GmbH.)

Background: Whether chronic pulmonary aspergillosis (CPA) has different immunophenotypes remains unknown., Objective: To identify different CPA immunophenotypes using cluster analysis., Methods: We used a subject-centred multivariate clustering approach without prior assumptions to identify CPA phenotypes. We retrospectively included the data of treatment-naïve subjects with CPA and excluded subjects with asthma and allergic bronchopulmonary aspergillosis (ABPA). We performed a scalable two-step cluster analysis using the log-likelihood distance measures to identify CPA phenotypes based on the blood immunological profile (total IgE, eosinophil count and Aspergillus-specific IgE and IgG)., Results: We included 351 CPA subjects and found two clusters. Cluster 2 (n = 118) had significantly higher serum total IgE, peripheral blood eosinophil count, and serum A. fumigatus-specific IgE and IgG than cluster 1 (n = 233). Cluster 2 subjects had a lower FEV1:FVC ratio on spirometry and were more likely to have a fungal ball (88 [74.6%] vs. 145 (62.2%), p = .023) on the CT thorax than cluster 1. After treatment discontinuation, cluster 2 had a longer median (interquartile range) time to relapse than cluster 1 (11.5 [7.3-27.4] vs. 4 [1.1-8.9] months, p = .005)., Conclusion: We identified two distinct CPA phenotypes, type-2 dominant and non-type-2, with different clinical and radiological findings and treatment outcomes. Future studies should confirm our findings and investigate different treatment strategies based on CPA phenotypes., (© 2022 Wiley-VCH GmbH.)

Background: Patients with persistent air leak (PAL) pose a therapeutic challenge to physicians, with prolonged hospital stays and high morbidity. There is little evidence on the efficacy and safety of bronchial valves (BV) for PAL., Methods: We systematically searched the PubMed and Embase databases to identify studies evaluating the efficacy and safety of BV for PAL. We calculated the success rate (complete resolution of air leak or removal of intercostal chest drain after bronchial valve placement and requiring no further procedures) of BV for PAL in individual studies. We pooled the data using a random-effects model and examined the factors influencing the success rate using multivariable meta-regression., Results: We analyzed 28 observational studies (2472 participants). The pooled success rate of bronchial valves in PAL was 82% (95% confidence intervals, 75 to 88; 95% prediction intervals, 64 to 92). We found a higher success rate in studies using intrabronchial valves versus endobronchial valves (84% vs. 72%) and in studies with more than 50 subjects (93% vs. 77%). However, none of the factors influenced the success rate of multivariable meta-regression. The overall complication rate was 9.1% (48/527). Granulation tissue was the most common complication reported followed by valve migration or expectoration and hypoxemia., Conclusion: Bronchial valves are an effective and safe option for treating PAL. However, the analysis is limited by the availability of only observational data., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics., Methods: An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively., Results: We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL -1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus -IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response., Conclusion: We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research., Competing Interests: Conflict of interest: R. Agarwal has received grants from Cipla Pharmaceuticals, India for conducting research in ABPA. D.W. Denning and family hold founder shares in F2G Ltd, a University of Manchester spin-out antifungal discovery company, and share options in TFF Pharma. He acts or has recently acted as a consultant to Pulmatrix, Pulmocide, Biosergen, TFF Pharmaceuticals, Rostra Therapeutics, Mucpharma PTY and Lifemine Therapeutics. In the last 3 years, he has been paid for talks on behalf of Mundipharma, Bio-Rad, Basilea, Gilead, Avir and Pfizer. He has been involved in multiple guideline groups, primarily focused on diagnostics and aspergillosis. D. Armstrong-James holds share options in Pulmocide Ltd. K. Asano is partially supported by a research grant on allergic disease and immunology from the Japan Agency for Medical Research and Development under grant number 22ek0410097. S.H. Chotirmall has served on advisory boards for CSL Behring, Pneumagen Ltd and Boehringer Ingelheim, on data monitoring boards for Inovio Pharmaceuticals and Imam Abdulrahman Bin Faisal University, and has received personal fees from AstraZeneca and Chiesi Farmaceutici, all unrelated to this work. H.J.F. Salzer has received honoraria for lectures or consulting fees from Ismed, GlaxoSmithKline, AstraZeneca, Advanz Pharma, MSD and Chiesi, all unrelated to this work. J.D. Chalmers has received research grants from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Gilead Sciences, Grifols, Novartis, Insmed and Trudell, and received consultancy or speaker fees from Antabio, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Insmed, Janssen, Novartis, Pfizer, Trudell and Zambon. C. Godet has received speaker fees and travel support from Pfizer and MSD, fees for board memberships from SOS Oxygène and Pulmatrix, and grant support from Ohre Pharma, Pfizer, MSD, SOS Oxygène, ISIS Medical, LVL Médical, Oxyvie, Vivisol, Elivie, CF Santé, Boehringer, Sandoz and AstraZeneca. M. Joest has received honoraria for lectures or grants from ALK-Abelló, AstraZeneca, Bencard, Berlin-Chemie, Boehringer Ingelheim, GlaxoSmithKline and HAL Allergy, all unrelated to this work. P. Nair reports grants and personal fees from AstraZeneca, Teva and Sanofi, personal fees from Equillium, Arrowhead Pharma and GlaxoSmithKline, and grants from Foresee and Cyclomedica, outside the submitted work. C.G. Baxter serves on strategic advisory board for Nob Hill Therapeutics Ltd. W.J. Calhoun is a member of the scientific advisory board of Pulmatrix, and that work is unrelated to this publication. O.A. Cornely reports grants from Cidara, F2G, Gilead, MSD, Mundipharma, Pfizer and Scynexis, consulting fees from AiCuris, Basilea, Cidara, Gilead, IQVIA, Matinas, Pfizer, PSI, Pulmocide and Scynexis, honoraria for lectures from Al-Jazeera, Gilead, Knight, MSD, Pfizer and Shionogi, and payment for expert testimony from Cidara. J.A. Douglass has received honoraria for educational presentations from AstraZeneca, GlaxoSmithKline, Novartis and CSL, has served on advisory boards for Sanofi-Aventis, Novartis, GlaxoSmithKline, AstraZeneca, Immunosis and CSL, and has undertaken contracted or investigator-initiated research on behalf of GlaxoSmithKline, Novartis, Immunosis, AstraZeneca, Sanofi-Aventis, Grifols, CSL, BioCryst and Equillium. R. Moss reports consulting fees from the Cystic Fibrosis Foundation, Astellas Pharma Inc., Nob Hill Therapeutics Inc., Pulmatrix, Mayne Pharma, Zambon Company SpA, Aridis Pharmaceuticals Inc., Regeneron Pharmaceuticals Inc. and 4D Molecular Therapeutics, royalties from UpToDate, Inc., and is a member of the board of directors for the Cystic Fibrosis Research Institute. D. Seidel received speaker fees from Pfizer, outside of the submitted work. R. Sprute has received speaker fees from Hikma and Pfizer, and travel support from Pfizer, all outside of the submitted work. The remaining authors have no potential conflicts of interest to disclose., (Copyright ©The authors 2024.)

Purpose: The search for an inexpensive agent for chemical pleurodesis in malignant pleural effusion (MPE) continues. We aimed to compare the efficacy and safety of iodopovidone versus doxycycline for pleurodesis in MPE., Methods: We randomized consecutive subjects with recurrent symptomatic MPE (1:1) to undergo pleurodesis with either doxycycline or iodopovidone administered through an intercostal tube. The primary outcome was the success rate of pleurodesis at 30 days. The secondary outcomes were the time to pleurodesis, chest pain (assessed using visual analog scale [VAS]) after pleurodesis, and complications (hypotension, acute respiratory failure, empyema)., Results: We randomized 52 and 58 subjects to receive either doxycycline or iodopovidone. The mean (standard deviation [SD]) age of the study population (51% women) was 54.1 (13.6) years. Lung cancer (≥ 60%) was the most common underlying cause of MPE. We observed a similar frequency of success in the doxycycline vs. the iodopovidone group (complete response: 43 (82.7%) vs. 46 (79.3%) subjects; partial response: 7 (13.5%) vs. 10 (17.2%) subjects; p = 0.3). The mean (SD) time to pleurodesis was 1.5 (1.9) days and 1.9 (5.4) days in the doxycycline and iodopovidone groups, respectively. While the VAS for chest pain was significantly higher with iodopovidone (mean [SD] VAS: doxycycline, 31.9 [20.9]; iodopovidone, 41.3 [21.8]; p = 0.017), it did not reach the minimal clinically important difference. The complication rates were similar between the two groups., Conclusion: Iodopovidone was not superior to doxycycline for pleurodesis in MPE. TRIAL REGISTRATION NUMBER/DATE: clinicaltrials.gov (NCT02583282) / October 22, 2015., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: There is limited data on prognostic value of baseline plasma cell free DNA (cfDNA) in advanced squamous non-small cell lung cancer (sq-NSCLC). This prospective observational study aimed to assess change in plasma cfDNA levels in locally-advanced/metastatic sq-NSCLC with chemotherapy and its correlation with symptom-scores and radiological-responses., Methods: Chemotherapy-naive patients with stages-IIIB/IIIC/IV sq-NSCLC ( n = 59), smokers with chronic obstructive pulmonary disease [COPD, COPD-controls (CC); n = 27] and healthy-controls ( n = 25) were enrolled. Respiratory symptom burden (RSB) and total symptom burden (TSB) were calculated from mean visual-analog-scores (VAS) of dyspnoea, cough, chest pain, hemoptysis RSB, anorexia and fatigue (all six for TSB). cfDNA was isolated from peripheral blood. All patients received platinum-doublet chemotherapy. RSB/TSB/cfDNA assessment and contrast-enhanced computed tomography (CECT)-thorax scans were done at baseline and post-chemotherapy., Results: At baseline, 13/59 (22%) sq-NSCLC, 3/27 (11%) CC and none (0%) healthy-controls had detectable cfDNA. All three CC were heavy smokers with no evidence of malignancy and undetectable cfDNA levels on repeat testing. In sq-NSCLC group, majority were males (95%), current-smokers (88%), heavy-smokers (70%), had metastatic disease (59%) with median age of 65 years. Eastern Co-operative Oncology Group (ECOG) performance status (PS) was 0-1 (56%) and 2 (42%). Median RSB- and TSB-scores were 9 [interquartile range (IQR) = 5-14] and 16 (IQR = 9-23), respectively. Of the 59 patients, 54 received ≥ 1 cycle while 27 underwent post-C4 evaluation with detectable cfDNA levels in 18/27 (66.7%). No baseline characteristic correlated with cfDNA detectability. Median overall survival (OS) and progression-free survival (PFS) were 262 days and 167 days, respectively. ECOG PS ≥ 2, RSB-score > 9 and TSB-score > 16 were all associated with worse OS and PFS as was cfDNA detectability [median OS = 97 days vs. 298 days and median PFS = 97 days vs. 197 days; P = 0.025; hazard ratio (HR) = 2.17]., Conclusions: Baseline cfDNA detectability is independently associated with poor OS and PFS in patients with advanced sq-NSCLC on chemotherapy., Competing Interests: The authors declare that they have no conflicts of interest., (© The Author(s) 2024.)

Introduction: Observational data suggest that the 19-gauge (G) needle for endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) offers a higher diagnostic yield than the 22-G needle in sarcoidosis. No randomized trial has compared the yield of the two needles., Methods: We randomized consecutive subjects with suspected sarcoidosis and enlarged thoracic lymph nodes to undergo EBUS-TBNA with either the 19-G or the 22-G needle. We compared the study groups for diagnostic sensitivity (primary outcome) assessed by the yield of granulomas in subjects finally diagnosed with sarcoidosis. We also compared the sample adequacy, difficulty performing the needle puncture assessed on a visual analog scale (VAS), the subject's cough intensity on an operator-rated VAS, and procedure-related complications (secondary outcomes)., Results: We randomized 150 (mean age, 43.0 years; 55% women) subjects and diagnosed sarcoidosis in 116 subjects. The diagnostic sensitivity of the 19-G needle (45/60, 75.0%) was not higher (p = 0.52) than the 22-G needle (39/56, 69.6%). We obtained adequate aspirates in 90.0% and 85.7% of subjects in the respective groups (p = 0.48). The operators had greater difficulty puncturing lymph nodes with the 19-G needle (p = 0.03), while the operator-assessed cough intensity was similar in the groups (p = 0.41). Transient hypoxemia was the only complication encountered during EBUS-TBNA (two subjects in either group)., Conclusion: We did not find the 19-G needle superior to the 22-G in diagnostic sensitivity, specimen adequacy, or safety of EBUS-TBNA in sarcoidosis. Puncturing the lymph nodes was more difficult with the 19-G needle., (© 2024 S. Karger AG, Basel.)

Background: The prevalence of allergic bronchopulmonary aspergillosis (ABPA) in Indian asthmatic patients remains unknown. We systematically reviewed the literature for estimating the prevalence of Aspergillus sensitization (AS) and ABPA in Indian subjects with bronchial asthma., Methods: We searched the PubMed and Embase databases for studies from India reporting the prevalence of AS or ABPA in at least 50 asthmatics. The primary outcome of our study was to assess the prevalence of ABPA. The secondary outcomes were to evaluate the prevalence of AS in asthma and ABPA in Aspergillus-sensitized asthma. We pooled the prevalence estimates using a random effects model and examined the factors influencing the prevalence using multivariate meta-regression., Results: Of the 8,383 records retrieved, 34 studies with 14,580 asthmatics met the inclusion criteria. All the studies were from tertiary centers. The pooled prevalence of ABPA in asthmatics (26 studies; 5,554 asthmatics) was 16.2% [95% confidence interval (CI), 12.5-20.4]. The pooled prevalence of AS in asthma (29 studies; 13,405 asthmatics) was 30.9% (95% CI, 25.3-36.6), while the prevalence of ABPA in AS (20 studies; 1,493 asthmatics) was 48.2% (95% CI, 39.6-56.8). Meta-regression identified studies published after 2009 (OR 1.14; 95% CI, 1.02-1.28) and studies with severe asthmatics (OR 1.12; 95% CI, 1.00-1.26) as the only factors associated with higher ABPA prevalence., Conclusions: There is a high prevalence of ABPA in Indian asthmatic subjects at tertiary centers, underscoring the need for screening all asthmatic subjects in special asthma and chest clinics for ABPA.

Background: There are few reports on the utility of bronchoscopic narrow-band imaging (NBI) for visualizing endobronchial abnormalities in sarcoidosis. Our primary objective was to compare the sensitivity of finding endobronchial abnormality using NBI versus white light bronchoscopy (WLB) in patients with sarcoidosis. The secondary aim was to evaluate the sensitivity of NBI in diagnosing endobronchial sarcoidosis against a reference standard of positive endobronchial biopsy (EBB)., Methods: We retrospectively included subjects with sarcoidosis, where we sequentially recorded WLB and NBI videos to visualize the endobronchial mucosa. We collected data on the demographic findings, sarcoidosis stage, and the histopathological findings of transbronchial needle aspiration, EBB, and transbronchial lung biopsy. Three experienced bronchoscopists viewed the video recordings and noted the abnormalities of the airway mucosa separately on WLB and NBI., Results: We included 28 subjects (mean age, 42.9 y; 53.6% men; 14 each, stages 1 and 2) with a final diagnosis of sarcoidosis. Granulomas were detected on EBB in 11 (39.3%) subjects. We identified endobronchial nodules in 10 and 15 subjects on WLB and NBI. The sensitivity of finding endobronchial abnormality using WLB and NBI was 35.7% (10/28) and 53.6% (15/28), respectively (χ 2 =1.77, df=1, P =0.18). The sensitivity of NBI in diagnosing endobronchial sarcoidosis against a positive EBB was 63.6% (7/11 subjects). There was excellent agreement (Κ=0.86) for detecting nodules on NBI among the 3 observers., Conclusion: NBI might allow the identification of additional abnormalities not detected on WLB in sarcoidosis. Larger studies are required to confirm our observations., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Mucormycosis in human immunodeficiency virus (HIV) infection is uncommon; notably, many cases have additional predisposing factors. Whether mucormycosis differs in HIV-affected individuals with and without additional risk factors (e.g., neutropenia, diabetes mellitus, and transplantation) remains unclear. In this systematic review, we identified 94 cases of HIV and mucormycosis classifiable into three groups: (1) HIV with additional risk factors (n = 50), (2) intravenous drug users (IVDU, n = 24), and (3) no other risk factor (n = 19) for mucormycosis. The most common presentation in IVDU was renal (41.7%) and cerebral mucormycosis (39.2%), whereas rhino-orbital mucormycosis (ROM, 4.2%) was uncommon. In the other two groups, ROM was the most common presentation. Rhizopus was the most frequently isolated Mucorales; however, in IVDU, Lichtheimia was the most common. The overall mortality was 53% and not significantly different in the three groups. Mucormycosis in HIV-infected individuals is rare without additional risk factors or IVDU., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: The prevalence and outcomes of allergic bronchopulmonary aspergillosis (ABPA) in the elderly remain unknown., Methods: We reviewed our database to identify the proportion of subjects diagnosed with ABPA at ≥60 years of age (ABPA-elderly). We compared the clinical features, treatment and outcomes of ABPA-elderly versus the non-elderly (ABPA diagnosed at <60 years of age)., Results: Between 2007 and 2019, we encountered 810 ABPA subjects with a mean age of 34.9 years (49.4% women). Of these, 43 (5.3%) were aged ≥60 years (ABPA-elderly). There was a trend towards lower median (interquartile range [IQR]) serum total IgE (4900 [2659-10000] vs. 7156 [23360-11963] IU/mL; P = .06) and Aspergillus fumigatus-specific IgE (12.3 [4.8-29.6] vs. 22.4 [7.7-41.5] kUA/L; P = .06) in the elderly than the non-elderly. Eosinophil counts were similar in the two groups. The median [IQR] number of segments involved by bronchiectasis (5 [2-9] vs. 7 [4-11]) was significantly lower in the ABPA-elderly (P = .001). The proportion of subjects experiencing ABPA exacerbations was significantly (P = .047) lower in the elderly (25.6%) vs. the non-elderly (40.8%). There was also a tendency towards a lower mean number of exacerbations in the elderly (155 vs. 208 exacerbation per 1000 person-years) than the non-elderly (P = .09). There was also a trend towards longer mean time to first exacerbation in the ABPA-elderly than the non-elderly (1612 vs. 1159 days)., Conclusion: ABPA was uncommon in the elderly. The bronchiectasis is less extensive with a trend towards lower immunological severity and fewer exacerbations in the elderly than the non-elderly subjects with ABPA., (© 2021 Wiley-VCH GmbH.)

Background: Current guidelines recommend 20-40 mg·day -1 of oral prednisolone for treating pulmonary sarcoidosis. Whether the higher dose (40 mg·day -1 ) can improve outcomes remains unknown., Methods: We conducted an investigator-initiated, single-centre, open-label, parallel-group, randomised controlled trial (ClinicalTrials.gov identifier NCT03265405). Consecutive subjects with pulmonary sarcoidosis were randomised (1:1) to receive either high-dose (40 mg·day -1 initial dose) or low-dose (20 mg·day -1 initial dose) oral prednisolone, tapered over 6 months. The primary outcome was the frequency of relapse or treatment failure at 18 months from randomisation. Key secondary outcomes included the time to relapse or treatment failure, overall response, change in forced vital capacity (FVC, in litres) at 6 and 18 months, treatment-related adverse effects and health-related quality of life (HRQoL) scores using the Sarcoidosis Health Questionnaire and Fatigue Assessment Scale., Findings: We included 86 subjects (43 in each group). 42 and 43 subjects completed treatment in the high-dose and low-dose groups, respectively, while 37 (86.0%) and 41 (95.3%), respectively, completed the 18-month follow-up. 20 (46.5%) subjects had relapse or treatment failure in the high-dose group and 19 (44.2%) in the low-dose group (p=0.75). The mean time to relapse/treatment failure was similar between the groups (high-dose 307 days versus low-dose 269 days, p=0.27). The overall response, the changes in FVC at 6 and 18 months and the incidence of adverse effects were also similar. Changes in HRQoL scores did not differ between the study groups., Interpretation: High-dose prednisolone was not superior to a lower dose in improving outcomes or the HRQoL in sarcoidosis and was associated with similar adverse effects., Competing Interests: Conflict of interest: All authors have nothing to disclose., (Copyright ©The authors 2023. For reproduction rights and permissions contact permissions@ersnet.org.)

Background: The effect of application of fingernail polish on S pO 2 measurement remains unclear. We conducted this systematic review to ascertain the impact of fingernail polish on S pO 2 measurement., Methods: We queried PubMed, Embase, and CINAHL databases for publications indexed through December 2022. We included studies providing paired S pO 2 data from fingertips without and after nail polish application or reporting the number of subjects whose S pO 2 could not be measured due to fingernail polish. We used random effects modeling to summarize standardized mean differences (SMDs) and corresponding 95% CI for different nail polish colors from comparative studies., Results: We retrieved 122 studies and included 21 publications, mostly performed on healthy volunteers. Of these, 17 (81.0%) studies had a low risk of bias. We summarized mean SMD for 10 nail polish colors (black, blue, brown, green, orange, pink, purple, red, white, and yellow) from 25 paired data sets on S pO 2 across 20 studies. We found small (likely clinically insignificant) but statistically significant differences in mean S pO 2 when fingers were coated with black, blue, brown, or purple nail polish (SMD -0.57, -0.47, -0.33, and -0.25, respectively; 95% CI -0.86 to -0.29, -0.84 to -0.10, -0.59 to -0.07, and -0.48 to -0.02, respectively). Only one of 4 studies reported a high proportion of unsuccessful oximeter readings from fingers painted with black (88.0%) or brown (36.0%) nail polish., Conclusions: Although fingernail polish of some colors can marginally reduce S pO 2 reading or occasionally impede S pO 2 measurement, the variability is clinically insignificant., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

Background: Factors associated with pulmonary mucormycosis (PM) among subjects with diabetes mellitus (DM) remain unclear. Following the coronavirus disease (COVID-19)-associated mucormycosis outbreak in India, specific environmental exposures (especially cattle dung exposure) were proposed as possible aetiology. We hypothesized that environmental factors are associated with PM. We compared subjects with DM with (cases) and without PM (controls)., Methods: In this case-control study, for each PM case, we included five unmatched diabetic controls (hospital [n = 2], community [n = 3]) without PM. We collected information on demography, COVID-19 infection, glycated haemoglobin% (HbA1c), the type of house (pucca vs. kutcha) where the participants reside, and other environmental factors. The primary exposure tested was cattle dung exposure (CDE; using cattle dung cakes as fuel or cattle handling). We performed a multivariate logistic regression to explore factors associated with PM and report the association as an adjusted odds ratio (OR) with 95% confidence intervals (CI)., Results: We enrolled 39 PM cases and 199 controls (hospital [n = 80], community [n = 119]). CDE (OR 0.68, 95% CI [0.14-3.31]; p = 0.63) was not associated with increased PM in DM. We found male sex (OR 4.07, 95% CI [1.16-14.31]), higher HbA1c (OR 1.51, 95% CI [1.18-16.32]), COVID-19 (OR 28.25, 95% CI [7.02-113.6]) and residence at kutcha house (OR 4.84, 95% CI [1.33-17.52]) associated with PM., Conclusion: Cattle dung exposure was not associated with PM in subjects with DM. Instead, male sex, poor glycaemic control, COVID-19 and the type of housing were associated with pulmonary mucormycosis., (© 2023 Wiley-VCH GmbH.)

Background: The role of nebulized amphotericin B (NAB) in managing pulmonary mucormycosis (PM) is unknown., Methods: In this open-label trial, we randomized PM subjects to receive either intravenous liposomal amphotericin B (control arm, 3-5 mg/kg/day) alone or along with nebulized amphotericin B deoxycholate (NAB, 10 mg twice a day, every alternate day). The primary outcomes were: (1) overall response ('success' [complete or partial response] or 'failure' [stable disease, progressive disease, or death]) at 6 weeks; and (2) the proportion of subjects with adverse events (AE). The key secondary outcome was 90-day mortality. We performed a modified intention-to-treat (mITT) analysis where we included only subjects receiving at least a single dose of NAB., Results: Fifteen and 17 subjects were randomized to the control and NAB arms; two died before the first dose of NAB. Finally, we included 30 subjects (15 in each arm; mean age 49.8 years; 80% men) for the mITT analysis. Diabetes mellitus (n = 27; 16/27 were COVID-19-associated PM) was the most common predisposing factor. The overall treatment success was not significantly different between the control and the NAB arms (71.4% vs. 53.3%; p = .45). Twenty-nine subjects experienced any AE, but none discontinued treatment. The 90-day mortality was not significantly different between the control (28.6%) and NAB arm (53.3%; p = .26)., Conclusion: Adjunctive NAB was safe but did not improve overall response at 6 weeks. A different dosing schedule or nebulized liposomal amphotericin B may still need evaluation. More research is needed to explore other treatment options for PM., (© 2023 Wiley-VCH GmbH.)

Background: Allergic bronchopulmonary aspergillosis (ABPA) is complicated by exacerbations in more than one-third of the subjects. Whether nebulized amphotericin B (NAB) therapy prevents ABPA exacerbations remains unclear., Objectives: The primary objective of this systematic review and meta-analysis was to determine the frequency of subjects remaining exacerbation-free, one year after initiating NAB. The key secondary objectives were the time to first exacerbation and the safety of NAB therapy., Methods: We searched the PubMed and Embase databases for studies evaluating ≥5 subjects of ABPA managed with NAB. We report the pooled proportion of ABPA subjects remaining exacerbation free after one year. For the randomized controlled trials (RCTs), we estimate the pooled risk difference (RD) of exacerbation-free status at one year with NAB versus the control arm., Results: We included five studies for our analysis; three were observational (n = 28) and two RCTs (n = 160). The pooled proportion (95% confidence interval [CI]) of subjects remaining exacerbation free with NAB at one year was 76% (62-88). The pooled RD (95% CI) of an exacerbation-free status at one year was 0.33 (-0.12 to 0.78) and was not significantly different between the NAB and control arms. The time to first exacerbation was longer with NAB than with the standard therapy. No serious adverse events were reported with NAB., Conclusion: NAB does not improve exacerbation-free status at one year; however, weak evidence suggests it delays ABPA exacerbations. More research using different dosing regimens is required., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: The diagnostic accuracy of immunoassays versus immunoprecipitation methods for detecting A.fumigatus-specific IgG in patients with allergic bronchopulmonary aspergillosis (ABPA) complicating asthma remains unclear., Methods: We performed a systematic review to identify studies describing both the methods in the same ABPA subjects. We assessed study quality using the QUADAS-2 tool. We derived the relative sensitivity and specificity using the HSROC meta-regression model. We calculated the number-needed-to-test using an immunoassay to detect one additional positive test in ABPA., Results: Our search yielded 20 studies (796 ABPA and 929 controls). The studies had a high risk of bias. The summary estimates for sensitivity and specificity of immunoprecipitation methods were 68.6% (95% CI, 48.4-83.5) and 93.8% (95% CI, 83.6-97.8), respectively, while for immunoassays they were 85.2% (95% CI, 73.3-92.3) and 84.6% (95% CI, 76.0-90.5), respectively. The relative sensitivity and specificity of immunoassays compared to immunoprecipitation tests were 1.29 (95% CI, 1.1-1.6) and 0.91 (95% CI, 0.85-0.97), respectively. The automated immunoassays (1.77; 95% CI, 1.1-2.8) had better relative sensitivity than the manual (1.1; 95% CI, 1.02-1.18) assays compared to immunoprecipitation. The relative specificity of manual immunoassays (0.95; 95% CI, 0.91-0.99) was significantly lower, while that of automated (0.88; 95% CI, 0.77-1.0) assays was lower but not statistically different. One additional positive result was detected for every six (95% CI, 5-7) tests performed with immunoassay (versus immunoprecipitation)., Conclusion: Compared to immunoprecipiation methods, automated immunoassays have higher sensitivity and similar specificity, manual immunoassays have higher sensitivity and lower specificity, while automated immunoassays have higher sensitivity and similar specificity for detecting A.fumigatus-IgG in patients with ABPA. [www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=309864]., (© 2022 Wiley-VCH GmbH.)

Background: The prevalence of allergic bronchopulmonary aspergillosis (ABPA) in asthmatic patients remains unclear and is likely different across geographic locales., Objective: To systematically review the literature for estimating the prevalence of Aspergillus sensitization (AS) and ABPA in adults with bronchial asthma., Methods: We searched the PubMed and Embase databases for studies reporting the prevalence of AS or ABPA in at least 50 asthmatic subjects. The primary outcome was to assess the prevalence of ABPA. The secondary outcome was to evaluate the prevalence of AS in asthma and that of ABPA in asthma with AS. We pooled the prevalence estimates using a random-effects model and examined the factors influencing the prevalence using multivariate meta-regression., Results: Of the 11,801 records retrieved, 86 studies with 25,770 asthmatic subjects met the inclusion criteria. Most of the studies were from tertiary care centers. The pooled prevalence of ABPA in asthma (47 studies; 9822 asthmatic subjects) was 11.3% (95% CI, 8.7-14.2). The pooled prevalence of AS in asthma (73 studies; 23,003 asthmatic subjects) was 25.1% (95% CI, 20.5-30.0), whereas the prevalence of ABPA in AS (36 studies; 2954 asthmatic subjects) was 37.0% (95% CI, 27.9-46.6). Multivariate meta-regression identified studies published from India (odds ratio, 1.11; 95% CI, 1.01-1.23) as the only factor associated with higher ABPA prevalence. There was presence of significant statistical heterogeneity and publication bias., Conclusions: We found a high prevalence of ABPA in adult asthmatic subjects, underscoring the need for screening for ABPA in all asthmatic subjects seeking tertiary care., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose: No study has compared neurally adjusted ventilator assist (NAVA) with adaptive support ventilation (ASV) during non-invasive ventilation (NIV) in subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD)., Materials and Methods: In this randomized controlled trial, we compared NAVA-NIV with ASV-NIV for delivering NIV in consecutive subjects with AECOPD. The primary outcome was NIV failure rate (invasive mechanical ventilation). The key secondary outcomes were number of NIV manipulations, asynchrony index, and 90-day mortality., Results: We enrolled 76 subjects (NAVA-NIV, n = 36, ASV-NIV, n = 40; 74% males) with a mean ± SD age of 61.4 ± 8.2 years. We found no difference in NIV failure rates between the two arms (NAVA-NIV vs. ASV-NIV; 8/36 [22.2%] vs. 8/40 [20%]; p = 0.83). The median physician manipulations for NIV were significantly less in the ASV-NIV arm than in the NAVA-NIV arm (2 [0.8-4] vs. 3 [2-5]; p= 0.014) during the initial 24-h. We found no difference in median asynchrony index (NAVA-NIV vs. ASV-NIV, 16.6% vs. 16.4%, p = 0.5) and 90-day mortality (22.2% vs. 17.5%, p = 0.67)., Conclusion: The use of NAVA-NIV was not superior to ASV-NIV in reducing NIV failure rates in AECOPD. Both NAVA-NIV and ASV-NIV had similar asynchrony index and 90-day mortality., Trial Registry: www., Clinicaltrials: gov (NCT04414891)., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The estimates of the minimal important difference (MID) for the Saint George's respiratory questionnaire (SGRQ) score in CPA remain unknown. We performed a retrospective analysis on treatment-naïve CPA subjects (n = 148) treated with six-month oral itraconazole therapy and completed SGRQ at baseline and six months. The study's objective was to estimate the MID for SGRQ. We used an anchor-based method to determine the MID and found the MID for SGRQ of 7.3., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology.)

Background & Objectives: The risk factors for clinically significant diffuse parenchymal lung abnormalities (CS-DPLA) persisting after severe coronavirus disease 2019 (COVID-19) pneumonia remain unclear. The present study was conducted to assess whether COVID-19 severity and other parameters are associated with CS-DPLA., Methods: The study participants included patients who recovered after acute severe COVID-19 and presented with CS-DPLA at two or six month follow up and control group (without CS-DPLA). Adults volunteers without any acute illness, chronic respiratory illness and without a history of severe COVID-19 were included as healthy controls for the biomarker study. The CS-DPLA was identified as a multidimensional entity involving clinical, radiological and physiological pulmonary abnormalities. The primary exposure was the neutrophil-lymphocyte ratio (NLR). Recorded confounders included age, sex, peak lactate dehydrogenase (LDH), advanced respiratory support (ARS), length of hospital stay (LOS) and others; associations were analyzed using logistic regression. The baseline serum levels of surfactant protein D, cancer antigen 15-3 and transforming growth factor-β (TGF-β) were also compared among cases, controls and healthy volunteers., Results: We identified 91/160 (56.9%) and 42/144 (29.2%) participants with CS-DPLA at two and six months, respectively. Univariate analyses revealed associations of NLR, peak LDH, ARS and LOS with CS-DPLA at two months and of NLR and LOS at six months. The NLR was not independently associated with CS-DPLA at either visit. Only LOS independently predicted CS-DPLA at two months [adjusted odds ratios (aOR) (95% confidence interval [CI]), 1.16 (1.07-1.25); P<0.001] and six months [aOR (95% CI) and 1.07 (1.01-1.12); P=0.01]. Participants with CS-DPLA at six months had higher baseline serum TGF-β levels than healthy volunteers., Interpretation and Conclusions: Longer hospital stay was observed to be the only independent predictor of CS-DPLA six months after severe COVID-19. Serum TGF-β should be evaluated further as a biomarker., Competing Interests: None

Background: Interferon-gamma (IFN-γ) down-regulates plasma procalcitonin (PCT), marker of inflammation. Chronic pulmonary aspergillosis (CPA) is associated with low IFN-γ levels. Thus, plasma PCT may be elevated in CPA and could have a role in diagnosing and monitoring treatment response in CPA. Herein, we investigate the diagnostic performance of plasma PCT in CPA., Methods: We extracted the demographic, clinical, radiological, treatment outcomes, and plasma PCT levels of CPA subjects and controls (previously treated pulmonary tuberculosis with radiological abnormalities on CT chest [diseased controls] and treatment naïve active pulmonary tuberculosis [PTB]). We treated CPA subjects with six months of oral itraconazole. We took 0.25 ng/mL as a cut-off value for PCT. The study's primary objective was to ascertain the diagnostic performance of PCT in diagnosing CPA. The key secondary outcome was to study the change in the plasma PCT levels after itraconazole therapy., Results: We included 190 CPA cases and 40 controls (diseased controls [n = 20] and active PTB [n = 20]). PCT was elevated (≥0.25 ng/mL) in only 7 (3.7%) subjects with CPA. The sensitivity and specificity of PCT (≥0.25 ng/mL) were 3.7% (1.5-7.4%) and 100 (91.2-100%), respectively. The area under the curve for plasma PCT was 0.48 (95% confidence interval, 0.39-0.58). The plasma PCT values were available in 93 subjects at six months. There was a significant decline in the median plasma levels of PCT after treatment; however, the PCT levels either increased or remained the same in 45% of the subjects., Conclusion: Plasma procalcitonin has poor performance in diagnosing and following subjects with CPA., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors.)

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a real-time, minimally invasive procedure for sampling intrathoracic lymph nodes. Herein, we discuss EBUS-guided procedures, their benefits, and drawbacks in diagnosing sarcoidosis., Areas Covered: We first describe the utility of various endosonographic imaging techniques like B-mode, elastography, and doppler imaging. We then review the diagnostic yield and safety of EBUS-TBNA and compare it with the other available diagnostic modalities. Subsequently, we discuss the technical aspects of EBUS-TBNA influencing the diagnostic yield. Recent advances in EBUS-guided diagnostics like EBUS-guided intranodal forceps biopsy (EBUS-IFB) and EBUS-guided transbronchial mediastinal cryobiopsy (EBMC) are reviewed. Finally, we summarize the advantages and disadvantages associated with EBUS-TBNA in sarcoidosis and provide an expert opinion on the optimal use of this procedure in patients with suspected sarcoidosis., Expert Opinion: EBUS-TBNA is a minimally invasive, safe procedure with a good diagnostic yield, and should be the preferred diagnostic modality for sampling intrathoracic lymph nodes in patients with suspected sarcoidosis. For optimal diagnostic yield, EBUS-TBNA should be combined with endobronchial biopsy (EBB) and transbronchial lung biopsy (TBLB). Newer endosonographic techniques like EBUS-IFB and EBMC might obviate the need for EBB and TBLB due to their superior diagnostic yield.

Purpose of Review: Allergic bronchopulmonary aspergillosis (ABPA) is a disease frequently complicating asthma and cystic fibrosis. ABPA is increasingly recognized in other obstructive lung diseases (OLDs), including chronic obstructive pulmonary disease (COPD) and noncystic fibrosis bronchiectasis. Herein, we summarize the recent developments in ABPA complicating OLDs., Recent Findings: Recent research has described the clinical features and natural history of ABPA complicating asthma in children and the elderly. We have gained insights into the pathophysiology of ABPA, especially the role of eosinophil extracellular trap cell death and mucus plugs. The utility of recombinant fungal antigens in the diagnosis of ABPA has been established. Newer, more sensitive criteria for the diagnosis of ABPA have been proposed. Although ABPA is uncommon in COPD and noncystic fibrosis bronchiectasis, aspergillus sensitization is more common and is associated with a higher exacerbation rate., Summary: Several advances have occurred in the diagnosis and treatment of ABPA in recent years. However, there is an unmet need for research into the genetic predisposition, pathophysiology, and treatment of ABPA. Apart from asthma and cystic fibrosis, patients with other OLDs also require evaluation for Aspergillus sensitization and ABPA., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)